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Evaluation of Hallux Valgus Correction With Versus Without Akin Proximal Phalanx Osteotomy
The Journal of Foot & Ankle Surgery 55 (2016) 910–914
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The Journal of Foot & Ankle Surgery journal homepage: www.jfas.org
Evaluation of Hallux Valgus Correction With Versus Without Akin Proximal Phalanx Osteotomy Naohiro Shibuya, DPM, MS, FACFAS 1, Jakob C. Thorud, DPM, MS, AACFAS 2, Lanster R. Martin, DPM 3, Britton S. Plemmons, DPM, AACFAS 3, Daniel C. Jupiter, PhD 4 1 Associate Professor, Department of Surgery, Texas A&M Health Science Center, College of Medicine, Temple, TX; Chief, Section of Podiatry, Central Texas Veterans Health Care System, Temple, TX; and Staff, Baylor Scott and White Health Care System, Temple, TX 2 Staff, Section of Podiatry, Surgical Services, Central Texas Veterans Health Care System, Temple, TX; and Staff, Baylor Scott and White Health Care System, Temple, TX 3 Podiatric Medicine and Surgery Resident, Scott and White Health Care System and Texas A&M Health Science Center, Temple, TX 4 Assistant Professor, Department of Preventive Medicine and Community Health, University of Texas Medical Branch, Galveston, TX
a r t i c l e i n f o
a b s t r a c t
Level of Clinical Evidence: 3
Although the efficacy of Akin proximal phalanx closing wedge osteotomy as a sole procedure for correction of hallux valgus deformity is questionable, when used in combination with other osseous corrective procedures, the procedure has been believed to be efficacious. However, a limited number of comparative studies have confirmed the value of this additional procedure. We identified patients who had undergone osseous hallux valgus correction with first metatarsal osteotomy or first tarsometatarsal joint arthrodesis with (n ¼ 73) and without (n ¼ 81) Akin osteotomy and evaluated their radiographic measurements at 3 points (preoperatively, within 3 months after surgery, and 6 months after surgery). We found that those people who had undergone the Akin procedure tended to have a larger hallux abduction angle and a more laterally deviated tibial sesamoid position preoperatively. Although the radiographic correction of the deformity was promising immediately after corrective surgery with the Akin osteotomy, maintenance of the correction was questionable in our cohort. The value of additional Akin osteotomy for correction of hallux valgus deformity is uncertain. Published by Elsevier Inc. On behalf of the American College of Foot and Ankle Surgeons.
Keywords: bunion metatarsus primus varus recurrence surgery tibial sesamoid position
Many different surgical procedures have been used to correct bunion deformity, each with its own merits and demerits. However, a limited number of comparative studies have been performed that recommend 1 procedure over the others. Many surgeons have relied on their experience, training, and study of case series to determine the best procedure for the correction of bunion deformity. Since O. F. Akin described a proximal phalanx closing wedge osteotomy for correction of hallux valgus deformity in 1925, many modifications to (1–7) and adjunctive fixation techniques (8–20) for this procedure have been described. It has been suggested that this procedure will be unpredictable or even unsatisfactory in many patients when used without any other osseous procedures for correction of hallux valgus deformity (21–24). However, many case series have shown clinically satisfactory results after the use of this procedure in conjunction with other metatarsus primus varus corrective osseous procedures (25–31). It has been suggested that
the procedure is useful to correct surgically induced hallux interphalangeus and reduce the retrograding force created by laterally deviated long flexors and extensors (32,33). The procedure as an adjunct procedure has been widely accepted by surgeons treating mild to severe hallux valgus deformity (34,35). However, it has been shown that the rate of recurrence of the deformity can still be high in juvenile and adolescent cohorts with mild to severe deformity, despite this additional proximal phalangeal osteotomy (36). Furthermore, a limited number of comparative, objective analyses have compared those with and without this additional Akin proximal osteotomy to judge the value of this procedure as an adjunct procedure for hallux valgus correction (37). The goal of the present study was to observe the characteristics of those patients who had undergone hallux valgus correction with or without Akin proximal osteotomy to evaluate its potential benefit relative to those corrective procedures without the Akin osteotomy.
Financial Disclosure: None reported. Conflict of Interest: None reported. Address correspondence to: Naohiro Shibuya, DPM, MS, FACFAS, Baylor Scott and White Health Care System, Temple, TX 76502. E-mail address: [email protected] (N. Shibuya).
Patients and Methods The present study was a retrospective cohort study evaluating patients who had undergone surgical correction of bunion deformity. The medical records, including plain radiographs at different points peri- and postoperatively, were evaluated. The
1067-2516/$ - see front matter Published by Elsevier Inc. On behalf of the American College of Foot and Ankle Surgeons. http://dx.doi.org/10.1053/j.jfas.2016.03.016
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patients were divided into 2 groups: 1 group, who had undergone ancillary Akin proximal phalanx closing wedge osteotomy, and 1 group who had not undergone this procedure. The pre- and postoperative characteristics of both groups were compared to evaluate the efficacy of this adjunctive procedure. The decision to perform this additional procedure was at the discretion of each surgeon. Patients were enrolled from the Scott and White Health Care System from January 1, 2004 to December 31, 2006. Our institution’s internal review board approved the study protocol. The patients who had undergone osseous hallux valgus corrective procedures were identified using any of the following Common Procedural Terminology codes: 28296 (metatarsal head osteotomy), 28297 (Lapidus-type procedure), 28299 (double osteotomy), 28306 (osteotomy with or without lengthening, shortening, or angular correction), 28740 (single first temporomandibular joint fusion), and 28750 (first metatarsophalangeal joint fusion). The radiographic review process confirmed the accuracy of the identification process using the Common Procedural Terminology codes. The patients were evaluated for the following inclusion and exclusion criteria. The inclusion criteria were patient age 18 to 80 years, availability of weightbearing radiographs taken within 1 year preoperatively, and availability of weightbearing radiographs within 3 and 6 months postoperatively. Those patients who had undergone revision bunionectomy were excluded. After enrollment, the demographic, physical, and surgical data were collected for each subject, including patient age at surgery, gender, weight in kilograms, height in centimeters, and operating surgeon. For radiographic examination, the hallux abductus angle (HAA; the angle created by the long axis of the proximal phalanx of the hallux and the long axis of the first metatarsal bone), the intermetatarsal angle (IMA; the angle created by the long axes of the first and second metatarsal bones), and the tibial sesamoid position (38) were evaluated at 3 different time points: preoperatively, within 3 months postoperatively, and 6 months postoperatively. In the case of a patient having undergone metatarsal osteotomy, the long axis was considered as that line connecting 2 points that bisect the distal and proximal ends of the corrected long bone. For the tibial sesamoid position, the 7-level grading system described by Hardy and Clapham (38) on the dorsoplantar view of a plain radiograph was used (Fig.). All these numerical values were treated as a continuous variable for the purposes of the present study. We did not evaluate the fixation techniques. The complication rates were also compared between the groups. These complications included postoperative wound dehiscence (separation of skin edges), infection requiring antibiotics (determined by each surgeon), revision surgery other than hardware removal, hardware removal, 1 nonunion at an osteotomy or arthrodesis site (radiographic incomplete bone healing in 2 of 3 views of plain films for >6 months). Statistical Analysis The demographic data, including age, weight, height, and proportion of each gender, were compared using Student’s t test or chi-square or Fisher’s exact tests, as appropriate, between the 2 groups. The mean pre- and postoperative angles (within 3 months and after 6 months) were calculated for each group and compared using the 2-way unpaired Student’s t test. The association of each complication with the Akin osteotomy was tested using the chi-square test or Fisher’s exact test. All statistical analyses were performed using the R statistical package by the primary author (N.S.; R Developmental Core Team; R: A Language and Environment for Statistical Computing 2012l available at http://www.R-project.org).
Results A total of 154 patients met the inclusion and exclusion criteria during the study period. Of the 154 patients, 142 were female and 12 were male. A total of 12 surgeons performed 1 studied procedure during the study period. Of the 12 surgeons, 5 performed 81% (125 of 154) of the procedures. None of the authors were among the 12 surgeons. The mean age in the patient cohort was 58 14.4 years. No statistically significant difference was found in the mean age, gender ratio, weight, or height between the Akin and non-Akin groups (Table 1). Also, no significant association was found between age, gender, weight, or height and the radiographic results at any of the 3 measurement points (p ¼ NS, Pearson’s correlation and Student’s t test). Of the 154 patients, 73 had undergone Akin osteotomy in addition to metatarsal osteotomy or arthrodesis, and 81 did not undergo proximal phalangeal osteotomy. The distribution of the primary osseous procedures in both groups is listed in Table 2. Most (103 of 154; 67%) of the patients had undergone distal metatarsal osteotomy as the primary procedure for hallux valgus deformity correction. The Akin osteotomy was performed in 40 of 103 patients (39%)
Fig. Tibial sesamoid position described by Hardy and Clapham (38).
who had undergone distal metatarsal osteotomy, 12 of 26 patients (46%) who had undergone Lapidus first tarsometatarsal arthrodesis, and 19 of 20 patients (95%) who had undergone closing base wedge metatarsal osteotomy. This difference in the proportions was statistically significant (p ¼ .001, Fisher’s exact test). No patient underwent Akin osteotomy as the sole procedure for correction of hallux valgus deformity. The normality of the radiographic measurements was confirmed using box plots and quantile-quantile plots. The preoperative IMAs were 14.2 3.65 and 13.4 4.25 in the groups with and without Akin osteotomy, respectively, and the difference was not statistically significant (p ¼ .188; Table 3). The postoperative IMAs on the 3-month radiographs were 8.3 and 8.3 with and without the Akin osteotomy, respectively, and the difference was not statistically significant (p ¼ .999). On the 6-month follow-up radiographs, the IMA in the Akin group was slightly greater (mean 9.5 3.65 ) than that in the
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Table 1 Patient characteristics for the Akin and non-Akin groups Characteristic Age (yr) Gender Female Male Height cm) Weight (kg) *
Akin Group (n ¼ 73) 57.7 66 7 164.0 79.1
Non-Akin Group (n ¼ 81)
p Value
58.7
.652
76 5 159.0 75.0
.433* .092 .253
Chi-square test.
non-Akin group (mean 8.6 4.25 ); however, this difference was not statistically significant (p ¼ .283). The preoperative HAA in the Akin group (mean 30.4 8.33 ) was significantly greater than that in the non-Akin group (mean 25.5 9.81 ; p ¼ .001; Table 3). Postoperatively, the difference was no longer significant (p ¼ .717), with an HAA for the Akin and non-Akin groups of 13.9 7.24 and 14.3 6.77, respectively. After 6 months, the Akin group had a statistically significantly greater HAA (mean 17.8 9.97 ) compared with that for the non-Akin group (mean 13.4 11.38 ; p ¼ .037). The preoperative tibial sesamoid position in the Akin group (mean 5.5 1.07) was significantly greater than that in the non-Akin group (mean 5.0 1.42; p ¼ .007). Postoperatively, the tibial sesamoid position was still statistically significantly greater in the Akin group (mean 3.9 1.42) than in the non-Akin group (mean 3.2 1.54; p ¼ .009), although the difference was smaller. This was still true on the radiographs taken 6 months postoperatively. The mean tibial sesamoid position in the Akin and non-Akin groups was 4.5 1.49 and 3.8 1.69, respectively (p ¼ .015). The frequency and percentage of complications in each group are listed in Table 4. No statistically detectable association was found between the use of the Akin osteotomy and any complications investigated in the present study. We also used multivariate linear models to analyze the association of Akin osteotomy with the radiographic measurements at the different measurement points, independent of the primary osseous procedures (Table 5), and we observed that the Akin osteotomy did not independently contribute to the reduction of the IMA, HAA, or tibial sesamoid position.
Discussion In the present retrospective study, we observed that surgeons used the Akin osteotomy in patients with a greater HAA and tibial sesamoid position. Although correction of both the IMA and the HAA were comparable between the 2 groups immediately after surgery, the HAA correction was not maintained at the longer follow-up point despite the addition of the Akin osteotomy. Although we were unable to determine whether maintenance of the correction would have been worse without the Akin osteotomy, in those with severe hallux valgus deformity with an increased tibial sesamoid position, the addition of this procedure did not seem, on subjective radiographic examination, to produce optimal mid- to long-term results. Further investigation is needed to determine
Table 2 Distribution of main bunion procedures in Akin and non-Akin groups
Table 3 IMA, HAA, and TSP before and after bunion deformity correction compared between Akin and non-Akin groups Akin Group (n ¼ 73)
Non-Akin Group (n ¼ 81)
p Value
3 mo 6 mo
14.2 8.3 9.5
13.4 8.3 8.6
.188 .999 .283
3 mo 6 mo
30.4 13.9 17.8
25.5 14.3 13.4
.001* .717 .037*
3 mo 6 mo
5.5 3.9 4.5
5.0 3.2 3.8
.007* .009* .015*
Variable IMA ( ) Preoperatively After surgery < After surgery > HAA ( ) Preoperatively After surgery < After surgery > TSP Preoperatively After surgery < After surgery >
Abbreviations: HAA, hallux abductus angle; IMA, intermetatarsal angle (first and second metatarsal); TSP, tibial sesamoid position. * Statistically significant.
how much the Akin procedure contributes to hallux valgus correction and maintenance in those with a severe deformity. Correction of the sesamoid position has been suggested as critical for the maintenance of bunion deformity correction (39). In the present study, the tibial sesamoid position was improved in the Akin group immediately after the surgery but was still comparatively greater than that in the non-Akin group, which had less deviation in the sesamoid and hallux abduction preoperatively. After 6 months, the Akin group appeared to be losing the correction of the sesamoid position. Correction of the IMA was comparable between the 2 groups, although a nonstatistically significant loss of correction was observed 6 months after surgery in the Akin group. Again, the greater preoperative tibial sesamoid position and HAA in the Akin group might have contributed to this outcome. No association was found between the performance of the Akin osteotomy and any of the complications investigated in the present study. Although the extra procedure added more dissection, operative time, and trauma, this did not result in significantly increased complication rates. It has been shown that proximal wedge osteotomy can induce hallux interphalangeus and might necessitate an additional procedure, such as the Akin osteotomy (32). In the present study, a significantly greater proportion of patients underwent the Akin osteotomy in the group who had undergone closing base wedge osteotomy as the primary procedure. Therefore, we decided to run post hoc analyses to judge the effect of the Akin osteotomy, independent of the primary procedures. Of the 154 patients who had undergone distal osteotomy, 149 (96%) had also undergone first tarsometatarsal arthrodesis or closing base wedge osteotomy. We removed patients who had undergone procedures labeled as “others” (n ¼ 4) and “first metatarsophalangeal arthrodesis” (n ¼ 1) from the following analyses. We evaluated the association of Akin osteotomy with the radiographic measurements at the different measurement points, independent of the primary osseous procedures, using multivariate linear models (Table 5). After these analyses, we found that the Akin osteotomy did not independently contribute to the reduction of the IMA, HAA, or tibial sesamoid position.
Table 4 Frequency and percentage of complications compared between Akin and non-Akin groups
Main Procedure
Akin Osteotomy No (n ¼ 81)
Yes (n ¼ 73)
Complication
Akin Group (n ¼ 73)
Non-Akin Group (n ¼ 81)
p Value
Distal metatarsal osteotomy First tarsometatarsal joint arthrodesis Proximal first metatarsal closing base wedge osteotomy Other metatarsal osteotomy First metatarsophalangeal joint arthrodesis
63 14 1 2 1
40 12 19 2 0
Wound dehiscence Infection Revision surgery Hardware removal Nonunion
4 8 13 12 3
4 5 9 13 4
.880 .292 .239 .703 .806
(5.5) (11.0) (17.8) (16.4) (4.1)
(4.9) (6.2) (11.1) (16.0) (4.9)
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Table 5 Linear models for effect of hallux valgus procedures on radiographic measurements at different measurement points (N ¼ 154 patients) Variable Preoperative IMA Distal metatarsal osteotomy (reference) Tarsometatarsal arthrodesis Proximal closing wedge metatarsal osteotomy Akin proximal phalanx osteotomy IMA <3 mo after surgery Distal metatarsal osteotomy (reference) Tarsometatarsal arthrodesis Proximal closing wedge metatarsal osteotomy Akin proximal phalanx osteotomy IMA >6 mo after surgery Distal metatarsal osteotomy (reference) Tarsometatarsal arthrodesis Proximal closing wedge metatarsal osteotomy Akin proximal phalanx osteotomy Preoperative HAA Distal metatarsal osteotomy (reference) Tarsometatarsal arthrodesis Proximal closing wedge metatarsal osteotomy Akin proximal phalanx osteotomy HAA <3 mo after surgery Distal metatarsal osteotomy (reference) Tarsometatarsal arthrodesis Proximal closing wedge metatarsal osteotomy Akin proximal phalanx osteotomy HAA >6 mo after surgery Distal metatarsal osteotomy (reference) Tarsometatarsal arthrodesis Proximal closing wedge metatarsal osteotomy Akin proximal phalanx osteotomy Preoperative TSP Distal metatarsal osteotomy (reference) Tarsometatarsal arthrodesis Proximal closing wedge metatarsal osteotomy Akin proximal phalanx osteotomy TSP <3 mo after surgery Distal metatarsal osteotomy (reference) Tarsometatarsal arthrodesis Proximal closing wedge metatarsal osteotomy Akin proximal phalanx osteotomy TSP >6 mo after surgery Distal metatarsal osteotomy (reference) Tarsometatarsal arthrodesis Proximal closing wedge metatarsal osteotomy Akin proximal phalanx osteotomy
Estimate
p Value
12.63 3.70 1.30 0.54
.001 .136 .361
8.28 0.22 1.85 0.59
.774 .043 .336
8.49 0.10 1.27 0.78
.928 .345 .370
23.20 9.47 6.85 3.89
.001 .002 .008
13.77 1.98 2.14 0.74
.202 .251 .557
12.41 2.67 5.30 3.92
.349 .146 .097
4.69 1.18 0.73 0.45
.001 .019 .032
3.15 0.38 0.27 0.75
.241 .499 .006
3.62 0.36 0.38 0.82
.390 .477 .020
Abbreviations: HAA, hallux abductus angle; IMA, intermetatarsal angle; TSP, tibial sesamoid position. Distal metatarsal osteotomy was set as a reference.
Lechler et al (37) compared the clinical and radiographic outcomes between those who had undergone chevron distal metatarsal osteotomy alone versus those who had undergone chevron distal metatarsal osteotomy with Akin proximal phalanx osteotomy. They randomly assigned patients with mild to moderate hallux valgus deformity into 1 of those 2 groups. In their study, the group with additional Akin osteotomy had a significantly greater reduction of the hallux valgus angle and tibial sesamoid position relative to the noAkin group, with no difference in the reduction amount of the IMA. However, in their cohort, just as in ours, both the hallux valgus angle and the tibial sesamoid position were greater preoperatively in the Akin group. Therefore, there might have been “more room” for improvement in the group. Both the hallux valgus angle and the tibial sesamoid position were in the acceptable range at the final follow-up point in both groups. It should also be noted that the overall severity of the bunions in their study, shown by the preoperative tibial sesamoid position (4.3 and 3.5 in the Akin and non-Akin groups, respectively) and IMA (12.2 and 9.8 in the Akin and non-Akin groups, respectively), was noticeably less than those in our cohort.
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The weaknesses of our study included the inconsistency in the surgeons’ surgical technique and postoperative protocols. We did not control for these elements in the present study; however, having multiple surgeons in the study mitigated the effect of any individual surgeon’s practice patterns. Also, we did not examine any clinical outcomes in the present study. Rather, we solely compared the radiographic measurements at 3 different points between the Akin and nonAkin groups. Therefore, excessive inferences of the clinical significance drawn from these findings should be avoided. Also, several potential confounders could have been present, such as underlying metatarsus adductus and flatfoot deformities, that could have potentially affected the outcomes. Although we did not stratify these variables in our analyses, we assumed that the surgeons’ decisions regarding whether to add the Akin osteotomy were not determined by these underlying deformities and that the distribution of these deformities was similar between the 2 groups. It should also be noted that the value of the Akin osteotomy on the correction of hallux interphalangeus and distal articular set angles was not evaluated in the present study. In conclusion, Akin osteotomies were used more often in those with more severe hallux valgus and an increased sesamoid position. Immediately postoperatively, the additional Akin osteotomy, in conjunction with the primary osseous procedure for correction of the hallux valgus deformity, was able to reduce the IMA, HAA, and sesamoid position; however, after 6 months postoperatively, the corrected hallux valgus angle and tibial sesamoid positions were not maintained in those who had undergone adjunctive surgery. The value of an additional Akin osteotomy for correction of severe hallux valgus deformity is uncertain.
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22. Steinbock G, Leder K. [The Akin-new method for surgery of hallux valgus: 1-year results of a covered surgical method]. Z Orthop Ihre Grenzgeb 126:420–424, 1988. 23. Plattner PF, Van Manen JW. Results of Akin type proximal phalangeal osteotomy for correction of hallux valgus deformity. Orthopedics 13:989–996, 1990. 24. Frey C, Jahss M, Kummer FJ. The Akin procedure: an analysis of results. Foot Ankle 12:1–6, 1991. 25. Mitchell LA, Baxter DE. A chevron-Akin double osteotomy for correction of hallux valgus. Foot Ankle 12:7–14, 1991. 26. Tollison ME, Baxter DE. Combination chevron plus Akin osteotomy for hallux valgus: should age be a limiting factor? Foot Ankle Int 18:477–481, 1997. 27. Roukis TS. Hallux proximal phalanx Akin-scarf osteotomy. J Am Podiatr Med Assoc 94:70–72, 2004. 28. Garrido IM, Rubio ER, Bosch MN, Gonzalez MS, Paz GB, Llabres AJ. Scarf and Akin osteotomies for moderate and severe hallux valgus: clinical and radiographic results. Foot Ankle Surg 14:194–203, 2008. 29. Kerr HL, Jackson R, Kothari P. Scarf-Akin osteotomy correction for hallux valgus: short-term results from a district general hospital. J Foot Ankle Surg 49:16–19, 2010. 30. Jung HG, Kim TH, Park JT, Shin MH, Lee SH. Proximal reverse chevron metatarsal osteotomy, lateral soft tissue release, and Akin osteotomy through a single medial incision for hallux valgus. Foot Ankle Int 35:368–373, 2014. 31. Al-Nammari SS, Christofi T, Clark C. Double first metatarsal and Akin osteotomy for severe hallux valgus. Foot Ankle Int 36:1215–1222, 2015.
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Evaluation of Hallux Valgus Correction With Versus Without Akin Proximal Phalanx Osteotomy Naohiro Shibuya, DPM, MS, FACFAS 1, Jakob C. Thorud, DPM, MS, AACFAS 2, Lanster R. Martin, DPM 3, Britton S. Plemmons, DPM, AACFAS 3, Daniel C. Jupiter, PhD 4 1 Associate Professor, Department of Surgery, Texas A&M Health Science Center, College of Medicine, Temple, TX; Chief, Section of Podiatry, Central Texas Veterans Health Care System, Temple, TX; and Staff, Baylor Scott and White Health Care System, Temple, TX 2 Staff, Section of Podiatry, Surgical Services, Central Texas Veterans Health Care System, Temple, TX; and Staff, Baylor Scott and White Health Care System, Temple, TX 3 Podiatric Medicine and Surgery Resident, Scott and White Health Care System and Texas A&M Health Science Center, Temple, TX 4 Assistant Professor, Department of Preventive Medicine and Community Health, University of Texas Medical Branch, Galveston, TX
a r t i c l e i n f o
a b s t r a c t
Level of Clinical Evidence: 3
Although the efficacy of Akin proximal phalanx closing wedge osteotomy as a sole procedure for correction of hallux valgus deformity is questionable, when used in combination with other osseous corrective procedures, the procedure has been believed to be efficacious. However, a limited number of comparative studies have confirmed the value of this additional procedure. We identified patients who had undergone osseous hallux valgus correction with first metatarsal osteotomy or first tarsometatarsal joint arthrodesis with (n ¼ 73) and without (n ¼ 81) Akin osteotomy and evaluated their radiographic measurements at 3 points (preoperatively, within 3 months after surgery, and 6 months after surgery). We found that those people who had undergone the Akin procedure tended to have a larger hallux abduction angle and a more laterally deviated tibial sesamoid position preoperatively. Although the radiographic correction of the deformity was promising immediately after corrective surgery with the Akin osteotomy, maintenance of the correction was questionable in our cohort. The value of additional Akin osteotomy for correction of hallux valgus deformity is uncertain. Published by Elsevier Inc. On behalf of the American College of Foot and Ankle Surgeons.
Keywords: bunion metatarsus primus varus recurrence surgery tibial sesamoid position
Many different surgical procedures have been used to correct bunion deformity, each with its own merits and demerits. However, a limited number of comparative studies have been performed that recommend 1 procedure over the others. Many surgeons have relied on their experience, training, and study of case series to determine the best procedure for the correction of bunion deformity. Since O. F. Akin described a proximal phalanx closing wedge osteotomy for correction of hallux valgus deformity in 1925, many modifications to (1–7) and adjunctive fixation techniques (8–20) for this procedure have been described. It has been suggested that this procedure will be unpredictable or even unsatisfactory in many patients when used without any other osseous procedures for correction of hallux valgus deformity (21–24). However, many case series have shown clinically satisfactory results after the use of this procedure in conjunction with other metatarsus primus varus corrective osseous procedures (25–31). It has been suggested that
the procedure is useful to correct surgically induced hallux interphalangeus and reduce the retrograding force created by laterally deviated long flexors and extensors (32,33). The procedure as an adjunct procedure has been widely accepted by surgeons treating mild to severe hallux valgus deformity (34,35). However, it has been shown that the rate of recurrence of the deformity can still be high in juvenile and adolescent cohorts with mild to severe deformity, despite this additional proximal phalangeal osteotomy (36). Furthermore, a limited number of comparative, objective analyses have compared those with and without this additional Akin proximal osteotomy to judge the value of this procedure as an adjunct procedure for hallux valgus correction (37). The goal of the present study was to observe the characteristics of those patients who had undergone hallux valgus correction with or without Akin proximal osteotomy to evaluate its potential benefit relative to those corrective procedures without the Akin osteotomy.
Financial Disclosure: None reported. Conflict of Interest: None reported. Address correspondence to: Naohiro Shibuya, DPM, MS, FACFAS, Baylor Scott and White Health Care System, Temple, TX 76502. E-mail address: [email protected] (N. Shibuya).
Patients and Methods The present study was a retrospective cohort study evaluating patients who had undergone surgical correction of bunion deformity. The medical records, including plain radiographs at different points peri- and postoperatively, were evaluated. The
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patients were divided into 2 groups: 1 group, who had undergone ancillary Akin proximal phalanx closing wedge osteotomy, and 1 group who had not undergone this procedure. The pre- and postoperative characteristics of both groups were compared to evaluate the efficacy of this adjunctive procedure. The decision to perform this additional procedure was at the discretion of each surgeon. Patients were enrolled from the Scott and White Health Care System from January 1, 2004 to December 31, 2006. Our institution’s internal review board approved the study protocol. The patients who had undergone osseous hallux valgus corrective procedures were identified using any of the following Common Procedural Terminology codes: 28296 (metatarsal head osteotomy), 28297 (Lapidus-type procedure), 28299 (double osteotomy), 28306 (osteotomy with or without lengthening, shortening, or angular correction), 28740 (single first temporomandibular joint fusion), and 28750 (first metatarsophalangeal joint fusion). The radiographic review process confirmed the accuracy of the identification process using the Common Procedural Terminology codes. The patients were evaluated for the following inclusion and exclusion criteria. The inclusion criteria were patient age 18 to 80 years, availability of weightbearing radiographs taken within 1 year preoperatively, and availability of weightbearing radiographs within 3 and 6 months postoperatively. Those patients who had undergone revision bunionectomy were excluded. After enrollment, the demographic, physical, and surgical data were collected for each subject, including patient age at surgery, gender, weight in kilograms, height in centimeters, and operating surgeon. For radiographic examination, the hallux abductus angle (HAA; the angle created by the long axis of the proximal phalanx of the hallux and the long axis of the first metatarsal bone), the intermetatarsal angle (IMA; the angle created by the long axes of the first and second metatarsal bones), and the tibial sesamoid position (38) were evaluated at 3 different time points: preoperatively, within 3 months postoperatively, and 6 months postoperatively. In the case of a patient having undergone metatarsal osteotomy, the long axis was considered as that line connecting 2 points that bisect the distal and proximal ends of the corrected long bone. For the tibial sesamoid position, the 7-level grading system described by Hardy and Clapham (38) on the dorsoplantar view of a plain radiograph was used (Fig.). All these numerical values were treated as a continuous variable for the purposes of the present study. We did not evaluate the fixation techniques. The complication rates were also compared between the groups. These complications included postoperative wound dehiscence (separation of skin edges), infection requiring antibiotics (determined by each surgeon), revision surgery other than hardware removal, hardware removal, 1 nonunion at an osteotomy or arthrodesis site (radiographic incomplete bone healing in 2 of 3 views of plain films for >6 months). Statistical Analysis The demographic data, including age, weight, height, and proportion of each gender, were compared using Student’s t test or chi-square or Fisher’s exact tests, as appropriate, between the 2 groups. The mean pre- and postoperative angles (within 3 months and after 6 months) were calculated for each group and compared using the 2-way unpaired Student’s t test. The association of each complication with the Akin osteotomy was tested using the chi-square test or Fisher’s exact test. All statistical analyses were performed using the R statistical package by the primary author (N.S.; R Developmental Core Team; R: A Language and Environment for Statistical Computing 2012l available at http://www.R-project.org).
Results A total of 154 patients met the inclusion and exclusion criteria during the study period. Of the 154 patients, 142 were female and 12 were male. A total of 12 surgeons performed 1 studied procedure during the study period. Of the 12 surgeons, 5 performed 81% (125 of 154) of the procedures. None of the authors were among the 12 surgeons. The mean age in the patient cohort was 58 14.4 years. No statistically significant difference was found in the mean age, gender ratio, weight, or height between the Akin and non-Akin groups (Table 1). Also, no significant association was found between age, gender, weight, or height and the radiographic results at any of the 3 measurement points (p ¼ NS, Pearson’s correlation and Student’s t test). Of the 154 patients, 73 had undergone Akin osteotomy in addition to metatarsal osteotomy or arthrodesis, and 81 did not undergo proximal phalangeal osteotomy. The distribution of the primary osseous procedures in both groups is listed in Table 2. Most (103 of 154; 67%) of the patients had undergone distal metatarsal osteotomy as the primary procedure for hallux valgus deformity correction. The Akin osteotomy was performed in 40 of 103 patients (39%)
Fig. Tibial sesamoid position described by Hardy and Clapham (38).
who had undergone distal metatarsal osteotomy, 12 of 26 patients (46%) who had undergone Lapidus first tarsometatarsal arthrodesis, and 19 of 20 patients (95%) who had undergone closing base wedge metatarsal osteotomy. This difference in the proportions was statistically significant (p ¼ .001, Fisher’s exact test). No patient underwent Akin osteotomy as the sole procedure for correction of hallux valgus deformity. The normality of the radiographic measurements was confirmed using box plots and quantile-quantile plots. The preoperative IMAs were 14.2 3.65 and 13.4 4.25 in the groups with and without Akin osteotomy, respectively, and the difference was not statistically significant (p ¼ .188; Table 3). The postoperative IMAs on the 3-month radiographs were 8.3 and 8.3 with and without the Akin osteotomy, respectively, and the difference was not statistically significant (p ¼ .999). On the 6-month follow-up radiographs, the IMA in the Akin group was slightly greater (mean 9.5 3.65 ) than that in the
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Table 1 Patient characteristics for the Akin and non-Akin groups Characteristic Age (yr) Gender Female Male Height cm) Weight (kg) *
Akin Group (n ¼ 73) 57.7 66 7 164.0 79.1
Non-Akin Group (n ¼ 81)
p Value
58.7
.652
76 5 159.0 75.0
.433* .092 .253
Chi-square test.
non-Akin group (mean 8.6 4.25 ); however, this difference was not statistically significant (p ¼ .283). The preoperative HAA in the Akin group (mean 30.4 8.33 ) was significantly greater than that in the non-Akin group (mean 25.5 9.81 ; p ¼ .001; Table 3). Postoperatively, the difference was no longer significant (p ¼ .717), with an HAA for the Akin and non-Akin groups of 13.9 7.24 and 14.3 6.77, respectively. After 6 months, the Akin group had a statistically significantly greater HAA (mean 17.8 9.97 ) compared with that for the non-Akin group (mean 13.4 11.38 ; p ¼ .037). The preoperative tibial sesamoid position in the Akin group (mean 5.5 1.07) was significantly greater than that in the non-Akin group (mean 5.0 1.42; p ¼ .007). Postoperatively, the tibial sesamoid position was still statistically significantly greater in the Akin group (mean 3.9 1.42) than in the non-Akin group (mean 3.2 1.54; p ¼ .009), although the difference was smaller. This was still true on the radiographs taken 6 months postoperatively. The mean tibial sesamoid position in the Akin and non-Akin groups was 4.5 1.49 and 3.8 1.69, respectively (p ¼ .015). The frequency and percentage of complications in each group are listed in Table 4. No statistically detectable association was found between the use of the Akin osteotomy and any complications investigated in the present study. We also used multivariate linear models to analyze the association of Akin osteotomy with the radiographic measurements at the different measurement points, independent of the primary osseous procedures (Table 5), and we observed that the Akin osteotomy did not independently contribute to the reduction of the IMA, HAA, or tibial sesamoid position.
Discussion In the present retrospective study, we observed that surgeons used the Akin osteotomy in patients with a greater HAA and tibial sesamoid position. Although correction of both the IMA and the HAA were comparable between the 2 groups immediately after surgery, the HAA correction was not maintained at the longer follow-up point despite the addition of the Akin osteotomy. Although we were unable to determine whether maintenance of the correction would have been worse without the Akin osteotomy, in those with severe hallux valgus deformity with an increased tibial sesamoid position, the addition of this procedure did not seem, on subjective radiographic examination, to produce optimal mid- to long-term results. Further investigation is needed to determine
Table 2 Distribution of main bunion procedures in Akin and non-Akin groups
Table 3 IMA, HAA, and TSP before and after bunion deformity correction compared between Akin and non-Akin groups Akin Group (n ¼ 73)
Non-Akin Group (n ¼ 81)
p Value
3 mo 6 mo
14.2 8.3 9.5
13.4 8.3 8.6
.188 .999 .283
3 mo 6 mo
30.4 13.9 17.8
25.5 14.3 13.4
.001* .717 .037*
3 mo 6 mo
5.5 3.9 4.5
5.0 3.2 3.8
.007* .009* .015*
Variable IMA ( ) Preoperatively After surgery < After surgery > HAA ( ) Preoperatively After surgery < After surgery > TSP Preoperatively After surgery < After surgery >
Abbreviations: HAA, hallux abductus angle; IMA, intermetatarsal angle (first and second metatarsal); TSP, tibial sesamoid position. * Statistically significant.
how much the Akin procedure contributes to hallux valgus correction and maintenance in those with a severe deformity. Correction of the sesamoid position has been suggested as critical for the maintenance of bunion deformity correction (39). In the present study, the tibial sesamoid position was improved in the Akin group immediately after the surgery but was still comparatively greater than that in the non-Akin group, which had less deviation in the sesamoid and hallux abduction preoperatively. After 6 months, the Akin group appeared to be losing the correction of the sesamoid position. Correction of the IMA was comparable between the 2 groups, although a nonstatistically significant loss of correction was observed 6 months after surgery in the Akin group. Again, the greater preoperative tibial sesamoid position and HAA in the Akin group might have contributed to this outcome. No association was found between the performance of the Akin osteotomy and any of the complications investigated in the present study. Although the extra procedure added more dissection, operative time, and trauma, this did not result in significantly increased complication rates. It has been shown that proximal wedge osteotomy can induce hallux interphalangeus and might necessitate an additional procedure, such as the Akin osteotomy (32). In the present study, a significantly greater proportion of patients underwent the Akin osteotomy in the group who had undergone closing base wedge osteotomy as the primary procedure. Therefore, we decided to run post hoc analyses to judge the effect of the Akin osteotomy, independent of the primary procedures. Of the 154 patients who had undergone distal osteotomy, 149 (96%) had also undergone first tarsometatarsal arthrodesis or closing base wedge osteotomy. We removed patients who had undergone procedures labeled as “others” (n ¼ 4) and “first metatarsophalangeal arthrodesis” (n ¼ 1) from the following analyses. We evaluated the association of Akin osteotomy with the radiographic measurements at the different measurement points, independent of the primary osseous procedures, using multivariate linear models (Table 5). After these analyses, we found that the Akin osteotomy did not independently contribute to the reduction of the IMA, HAA, or tibial sesamoid position.
Table 4 Frequency and percentage of complications compared between Akin and non-Akin groups
Main Procedure
Akin Osteotomy No (n ¼ 81)
Yes (n ¼ 73)
Complication
Akin Group (n ¼ 73)
Non-Akin Group (n ¼ 81)
p Value
Distal metatarsal osteotomy First tarsometatarsal joint arthrodesis Proximal first metatarsal closing base wedge osteotomy Other metatarsal osteotomy First metatarsophalangeal joint arthrodesis
63 14 1 2 1
40 12 19 2 0
Wound dehiscence Infection Revision surgery Hardware removal Nonunion
4 8 13 12 3
4 5 9 13 4
.880 .292 .239 .703 .806
(5.5) (11.0) (17.8) (16.4) (4.1)
(4.9) (6.2) (11.1) (16.0) (4.9)
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Table 5 Linear models for effect of hallux valgus procedures on radiographic measurements at different measurement points (N ¼ 154 patients) Variable Preoperative IMA Distal metatarsal osteotomy (reference) Tarsometatarsal arthrodesis Proximal closing wedge metatarsal osteotomy Akin proximal phalanx osteotomy IMA <3 mo after surgery Distal metatarsal osteotomy (reference) Tarsometatarsal arthrodesis Proximal closing wedge metatarsal osteotomy Akin proximal phalanx osteotomy IMA >6 mo after surgery Distal metatarsal osteotomy (reference) Tarsometatarsal arthrodesis Proximal closing wedge metatarsal osteotomy Akin proximal phalanx osteotomy Preoperative HAA Distal metatarsal osteotomy (reference) Tarsometatarsal arthrodesis Proximal closing wedge metatarsal osteotomy Akin proximal phalanx osteotomy HAA <3 mo after surgery Distal metatarsal osteotomy (reference) Tarsometatarsal arthrodesis Proximal closing wedge metatarsal osteotomy Akin proximal phalanx osteotomy HAA >6 mo after surgery Distal metatarsal osteotomy (reference) Tarsometatarsal arthrodesis Proximal closing wedge metatarsal osteotomy Akin proximal phalanx osteotomy Preoperative TSP Distal metatarsal osteotomy (reference) Tarsometatarsal arthrodesis Proximal closing wedge metatarsal osteotomy Akin proximal phalanx osteotomy TSP <3 mo after surgery Distal metatarsal osteotomy (reference) Tarsometatarsal arthrodesis Proximal closing wedge metatarsal osteotomy Akin proximal phalanx osteotomy TSP >6 mo after surgery Distal metatarsal osteotomy (reference) Tarsometatarsal arthrodesis Proximal closing wedge metatarsal osteotomy Akin proximal phalanx osteotomy
Estimate
p Value
12.63 3.70 1.30 0.54
.001 .136 .361
8.28 0.22 1.85 0.59
.774 .043 .336
8.49 0.10 1.27 0.78
.928 .345 .370
23.20 9.47 6.85 3.89
.001 .002 .008
13.77 1.98 2.14 0.74
.202 .251 .557
12.41 2.67 5.30 3.92
.349 .146 .097
4.69 1.18 0.73 0.45
.001 .019 .032
3.15 0.38 0.27 0.75
.241 .499 .006
3.62 0.36 0.38 0.82
.390 .477 .020
Abbreviations: HAA, hallux abductus angle; IMA, intermetatarsal angle; TSP, tibial sesamoid position. Distal metatarsal osteotomy was set as a reference.
Lechler et al (37) compared the clinical and radiographic outcomes between those who had undergone chevron distal metatarsal osteotomy alone versus those who had undergone chevron distal metatarsal osteotomy with Akin proximal phalanx osteotomy. They randomly assigned patients with mild to moderate hallux valgus deformity into 1 of those 2 groups. In their study, the group with additional Akin osteotomy had a significantly greater reduction of the hallux valgus angle and tibial sesamoid position relative to the noAkin group, with no difference in the reduction amount of the IMA. However, in their cohort, just as in ours, both the hallux valgus angle and the tibial sesamoid position were greater preoperatively in the Akin group. Therefore, there might have been “more room” for improvement in the group. Both the hallux valgus angle and the tibial sesamoid position were in the acceptable range at the final follow-up point in both groups. It should also be noted that the overall severity of the bunions in their study, shown by the preoperative tibial sesamoid position (4.3 and 3.5 in the Akin and non-Akin groups, respectively) and IMA (12.2 and 9.8 in the Akin and non-Akin groups, respectively), was noticeably less than those in our cohort.
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The weaknesses of our study included the inconsistency in the surgeons’ surgical technique and postoperative protocols. We did not control for these elements in the present study; however, having multiple surgeons in the study mitigated the effect of any individual surgeon’s practice patterns. Also, we did not examine any clinical outcomes in the present study. Rather, we solely compared the radiographic measurements at 3 different points between the Akin and nonAkin groups. Therefore, excessive inferences of the clinical significance drawn from these findings should be avoided. Also, several potential confounders could have been present, such as underlying metatarsus adductus and flatfoot deformities, that could have potentially affected the outcomes. Although we did not stratify these variables in our analyses, we assumed that the surgeons’ decisions regarding whether to add the Akin osteotomy were not determined by these underlying deformities and that the distribution of these deformities was similar between the 2 groups. It should also be noted that the value of the Akin osteotomy on the correction of hallux interphalangeus and distal articular set angles was not evaluated in the present study. In conclusion, Akin osteotomies were used more often in those with more severe hallux valgus and an increased sesamoid position. Immediately postoperatively, the additional Akin osteotomy, in conjunction with the primary osseous procedure for correction of the hallux valgus deformity, was able to reduce the IMA, HAA, and sesamoid position; however, after 6 months postoperatively, the corrected hallux valgus angle and tibial sesamoid positions were not maintained in those who had undergone adjunctive surgery. The value of an additional Akin osteotomy for correction of severe hallux valgus deformity is uncertain.
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